Adverse Childhood Experiences and Sleep Disturbances Among Puerto Rican Young Adults

Key Points Question Are prospectively and retrospectively reported adverse childhood experiences (ACEs) associated with sleep disturbances among Puerto Rican young adults? Findings In this cohort study that included 813 Puerto Rican young adults, higher numbers of retrospectively reported ACEs were significantly associated with greater sleep disturbance, while prospectively reported ACEs were not significantly associated with greater sleep disturbance. Meaning This study suggests that retrospectively reported ACEs are significantly associated with sleep disturbances among Puerto Rican young adults, after adjusting for sociodemographic factors.


Introduction
Sleep quality is a known marker of overall health and is a chronic health issue in the US. 1,2In addition to the racial and ethnic disparities affecting sleep quality, studies suggest that adverse childhood experiences (ACEs) are associated with sleep disturbances and other chronic diseases among adults. 3,4ACEs are defined as stressful or traumatic life events that occur during the first 18 years of life. 56][7] Our research group previously found a significant association between childhood adversity and poor sleep outcomes among Puerto Rican children. 8Although ACEs can be assessed both prospectively during childhood and retrospectively in adulthood, no previous study on ACEs and sleep quality has used both forms of reporting, to our knowledge.Despite the utility of retrospective ACEs and patient preference to be screened, both patients and physicians reported that fewer than 10% of adult patients were asked about ACEs. 9,10Furthermore, research has shown low agreement between prospective and retrospective ACEs, suggesting that these 2 forms of reporting may identify distinct groups of people with unique risk factors for various health outcomes. 11,12mpared with previous research on ACEs and sleep, our study introduces a new age group to consider: young adults.Young adults, defined as approximately 18 to 26 years of age, are an underrepresented population in research. 13Young adulthood is a critical period of complex cognitive and emotional maturation, including increased rates of risky behavior and accidental death. 13Despite the high incidence of mental and physical health issues among young adults, this population is less likely to seek health care or undergo routine screening compared with other age groups. 14nsidering the disparities in research that exist for Puerto Rican young adults, as well as the promising importance of exploring both retrospective and prospective ACEs, our study examines the association of prospective and retrospective ACEs with sleep quality in a geographically diverse population of Puerto Rican young adults.Understanding this association has the potential to inform interventions to address ACEs, improve sleep quality, and reduce health disparities for Puerto Rican young adults.

Study Population
Study participants are from the Boricua Youth Study (BYS), a longitudinal cohort of Puerto Rican children living in the South Bronx, New York, and Puerto Rico from August 2000 to August 2003.
Details on the study sampling, design, and procedures can be found elsewhere. 15In brief, 2491 Puerto Rican children and adolescents aged 5 to 13 years old were recruited at baseline from South Bronx, New York (n = 1138), and the standard metropolitan area of San Juan and Caguas, Puerto Rico (n = 1353).Eligibility criteria for the BYS included having at least 1 child in the household who was 5 to 13 years of age and at least 1 parent or primary caretaker of Puerto Rican descent.Participant ethnicity was assessed through a questionnaire.The BYS Health Assessment (HA) recruited a subsample of those who were 5 to 9 years of age at enrollment and participated in wave 4   17,18 Responses were characterized as binary variables: yes or no.ACEs were then reported retrospectively by young adults in the HA using a 10-item questionnaire from the original ACEs study. 17Because these surveys differed, we used the 8 overlapping items that were present in both surveys to conduct the analysis for this study.The number of ACEs was categorized into 4 groups (0 ACEs, 1 ACE, 2-3 ACEs, and Ն4 ACEs).

Main Outcome: Sleep Quality
Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI) in young adulthood at the same time that retrospective ACEs were collected in the HA study. 19

Statistical Analysis
Statistical analysis was performed from January 2023 to January 2024.Univariable analyses were conducted in the overall sample to examine the distribution of ACEs and sociodemographic factors.
Sociodemographic information included self-reported age (in years), sex (male or female), receipt of public assistance (yes or no), highest education grade completed, and geographical location in childhood (South Bronx or Puerto Rico).Separate multivariable linear regression models were used to examine the association of sleep quality with retrospective ACEs and prospective ACEs as both continuous and categorical variables, adjusting for covariates.Unstandardized β coefficients and 95% CIs were calculated from these models.A cross-product term between ACEs and the study site variable was included in the model to assess for interaction by site.Type III tests were used to examine statistical significance of the interaction term.
Similarly, log-binomial multivariable regression models were used to examine the association of retrospective and prospective ACEs with sleep quality as a dichotomous variable, adjusting for all covariates.Relative risks and 95% CIs were estimated from these models.All analyses included study sample weights to account for the unequal probability of selection into the study based on each site's sampling design and to be representative of the age and sex distributions of the 2000 US Census.
Nonresponse weights were calculated using a logistic regression model that included participant and parent characteristics associated with responding to the HA study.The final analysis weights were then calculated as a product of the HA nonresponse weights and the original BYS sampling weights to reflect the BYS reference population in each site.Analyses were conducted in SAS, version 9.4 (SAS Institute Inc).All P values were from 2-sided tests, and results were deemed statistically significant at P < .05.

Results
Participant characteristics in the overall sample and by study site are shown in A correlation analysis of retrospective and prospective ACEs showed a low but statistically significant correlation between these 2 measures (r = 0.134; P < .001).When prospective ACEs were examined as a categorical variable and adjusted for covariates, no level of ACEs was found to be significantly associated with sleep quality (Table 2).When examined as a continuous variable and adjusted for covariates, prospective ACEs were not found to have a significant association with sleep quality (β [SE] = 0.05 [0.10]; 95% CI, -0.14 to 0.24; P = .59)(Table 3).
When retrospective ACEs were examined as a categorical variable and adjusted for covariates, higher levels of ACEs (Ն2 ACEs) were significantly associated with worse sleep outcomes (2-3 ACEs:  4).When retrospective ACEs were examined as a continuous variable and adjusted for covariates, they were found to be significantly associated with worse sleep outcomes (β [SE] = 0.29 [0.07]; 95% CI, 0.15-0.44;P < .001)(Table 5).In addition, these results did not vary significantly by site.

Discussion
In this cohort of 813 Puerto Rican young adults, retrospective ACEs were significantly associated with poor sleep quality, and prospective ACEs were not significantly associated with poor sleep quality, after controlling for sociodemographic factors.There are several hypotheses that may explain these findings.Research suggests that ACEs are associated with a stress and fear response that can lead to disruption in regular routines and sleep and circadian dysregulation. 17The difference in associations seen with prospective and retrospective ACEs may be due to the fact that prospective ACEs were gathered over the first 11 years of the child's life, resulting in a gap in reporting during the adolescent period.This gap could explain the appearance of overreporting in young adulthood, which may represent events that occurred during the adolescent period. 20Furthermore, research shows that retrospective ACEs are strongly associated with subjectively measured outcomes, such as the PSQI. 21Participants with retrospective ACEs could have demonstrated more enduring effects of ACEs, resulting in worse sleep outcomes in young adulthood compared with those who did not retrospectively report ACEs.This study also contributes to the growing body of evidence that supports the utility of both retrospective and prospective ACEs when assessing overall health. 11spite these strengths, there are some limitations of our study.3][24] Retrospective ACEs do not capture the exact timing of an event, while prospective ACEs provide a more specific timeline.Recall bias is a consideration when observing the results from the retrospective measures, although research shows no evidence of recall bias in the retrospective assessment. 25There is also the possibility of reporter bias with retrospective ACEs, as the same informant is reporting on the exposure and outcome at the same time.However, reporter bias from retrospective ACEs has been shown to have the potential to

Strengths and Limitations
There are several strengths to this study.Most studies on ACEs and sleep quality focus on Asian and White populations, but our study diversified the Hispanic or Latino diaspora by focusing on Puerto Ricans.The geographical diversity of this cohort allowed us to examine whether social context may modify the association between ACEs and sleep quality.Furthermore, our study prioritized an understudied age group to highlight the specific circumstances of young adults, which has potential clinical relevance for supporting the pediatric-to-adult transition in medical care.Other strengths of this study include the large sample size, longitudinal design, and high compliance rate at follow-up.

16 Main Exposure: ACEs Prospective
ACEs are defined as those reported in childhood, and retrospective ACEs are defined as those reported in young adulthood.Prospective ACEs were reported by parents and youths using

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A summary score was generated by summing the 7 components of the PSQI, which included subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medications, and daytime dysfunction.A binary variable was created to categorize scores greater than 5 as poor sleep and scores of 5 or lower as good sleep.

Table 1 .
In the sample and 544 participants (66.9%) reported having at least 1 retrospective ACE.Compared with participants from Puerto Rico, those from the Bronx had, on average, worse sleep quality (mean [SE] PSQI, 5.7 [0.2] in the Bronx and 4.8 [0.2] in Puerto Rico), higher mean (SE) levels of prospective ACEs (1.4 [0.1] in the Bronx and 1.2 [0.1] in Puerto Rico), and higher mean (SE) levels of retrospective ACEs (1.7 [0.1] in the Bronx and 1.0 [0.1] in Puerto Rico).

Table 2 .
Association Between Prospectively Reported ACEs as a Categorical Variable and Sleep Quality a a Quality of evidence = 3, retrospective cohort study.bModel controlled for site, sex, age, educational level, and receiving public assistance.c Significant at P < .05.

Table 3 .
Association Between Prospectively Reported ACEs as a Continuous Variable and Sleep Quality a a Quality of evidence = 3, retrospective cohort study.bModel controlled for site, sex, age, educational level, and receiving public assistance.c Significant at P < .05.

Table 4 .
Association Between Retrospectively Reported ACEs as a Categorical Variable and Sleep Quality a Downloaded from jamanetwork.comby guest on 04/24/2024 When the PSQI was examined as a binary variable, participants with a greater number of retrospective ACEs were more likely to have poor sleep quality compared with those with fewer retrospective ACEs, after adjusting for sociodemographic factors (adjusted risk ratio, 1.22; 95% CI, 1.06-1.42).Prospective ACEs were not found to have a statistically significant association with poor sleep quality as a binary variable.
a Quality of evidence = 3, retrospective cohort study.bModel controlled for site, sex, age, educational level, and receiving public assistance.c Significant at P < .05.

Table 5 .
Association Between Retrospectively Reported ACEs as a Continuous Variable and Sleep Quality a